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Optimum Gold Rewards Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Optimum Gold Rewards Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Optimum Gold Rewards Plan (HMO) in 2025, please refer to our full plan details page.
Optimum Gold Rewards Plan (HMO) is a HMO plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Select Counties in Florida. This plan received an overall rating of 5 out of 5 stars in 2025.
It's important to know that Optimum Gold Rewards Plan (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Optimum Gold Rewards Plan (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Optimum Gold Rewards Plan (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3400.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Optimum Gold Rewards Plan (HMO) has an enhanced alternative drug benefit. This plan has no deductible for prescription drugs. In the initial coverage phase, you will pay a copay or coinsurance for your prescriptions, depending on the drug tier and pharmacy. For example, preferred generic drugs have a $47 copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Optimum Gold Rewards Plan (HMO) offers a range of benefits, including inpatient hospital stays with a $195 copay for the first 7 days, and no copay for days 8-90. Outpatient services have a $195 copay, while you'll have no copay for primary care, preventive care, hearing exams, vision exams, dental services, and home health services. This plan also covers ambulance services with a $200 copay for ground transport and 20% coinsurance for air ambulance, and offers no copay for transportation to plan-approved health-related locations (up to 6 trips per year). Emergency services have a $120 copay, and you'll have access to OTC items with a $45 monthly allowance. However, some services like podiatry, acupuncture, and certain dental and vision upgrades are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits for the Optimum Gold Rewards Plan (HMO) include coverage for both acute and psychiatric inpatient hospital stays. For days 1-7, the copay is $195 per stay, and for days 8-90, there is no copay. Additional days and non-Medicare-covered stays for both acute and psychiatric inpatient hospital stays are not covered.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services with a $195 copay, observation services with a $195 copay, ambulatory surgical center services with a $25 copay, and outpatient substance abuse services with a copay between $35 and $195 for individual and group sessions. Outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization and a doctor referral. You will have a $50 copay for this benefit.
Ambulance and Transportation Services See details
The Optimum Gold Rewards Plan (HMO) covers ambulance services with a $200 copay for ground ambulance services and 20% coinsurance for air ambulance services. Transportation services to a plan-approved health-related location are covered with no copay, for a maximum of 6 one-way trips per year, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $120 copay, Urgently Needed Services have a $20 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $500 copay.
Primary Care See details
The Optimum Gold Rewards Plan (HMO) covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $35 copay, physician specialist services with a $35 copay, mental health specialty services with a $35 copay for individual and group sessions, physical therapy and speech-language pathology services with a $35 copay, and opioid treatment program services with a copay between $0-$195. Podiatry services are not covered.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services, with no copay. Some additional preventive services are covered, but annual physical exams, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and other services are not covered.
Hearing Services See details
The Optimum Gold Rewards Plan (HMO) offers hearing services including hearing exams, routine hearing exams, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered up to $500 per year, with no copay for all types of prescription hearing aids. Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear, and OTC hearing aids are not covered.
Vision Services See details
The Optimum Gold Rewards Plan (HMO) covers vision services, including routine eye exams with no copay. Eyewear is covered with no copay, and includes a combined maximum of $100 per year for contact lenses and eyeglasses (lenses and frames), which have a $10 copay each, but eyeglass lenses and frames are not covered. Upgrades have a $30 copay.
Dental Services See details
The Optimum Gold Rewards Plan (HMO) covers dental services, including oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatments, periodontics, and oral and maxillofacial surgery with no copay. However, adjunctive general services, endodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Optimum Gold Rewards Plan (HMO), with the cost sharing for Medicare Part B Insulin Drugs including a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Optimum Gold Rewards Plan (HMO). You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment is covered by the Optimum Gold Rewards Plan (HMO), with Durable Medical Equipment (DME) subject to 20% coinsurance and Prosthetic Devices subject to 20% coinsurance. Medical Supplies have a 20% coinsurance, while Diabetic Supplies have a coinsurance between 0-20%, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures and tests with a copay of up to $195 and at least 20% coinsurance, lab services with no copay, diagnostic radiological services with a copay of at most $195, therapeutic radiological services with at least 20% coinsurance, and outpatient X-ray services with no copay. Prior authorization and a doctor referral are required.
Home Health Services See details
Home Health Services are covered by the Optimum Gold Rewards Plan (HMO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization and a referral.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover any of the sub-services, including Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services. Prior authorization and a doctor referral are required for coverage.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Optimum Gold Rewards Plan (HMO) with prior authorization and a doctor's referral. You will have no copay for days 1-5, a $20 copay for days 6-20, and a $150 copay for days 21-100, but additional days beyond Medicare coverage and non-Medicare-covered stays are not covered.
Other Services See details
The Optimum Gold Rewards Plan (HMO) covers Over-the-Counter (OTC) items with no copay, and a maximum benefit coverage amount of $45.00 every month. The plan does not cover acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services. The plan also covers a meal benefit with no copay, but requires prior authorization and a doctor referral.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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